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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />i2R5T166 <br />FACILITY ID # SERVICE REQUEST # <br />SRCJT8Gq -+G <br />OWNER / OPERATOR CHECK if BILLING ADDRESS Erick 3ovann GotIle os <br />FACILITY NAME 2.-rvip(Ak 5 e <br />SITE ADDRESS Lk -z, L_k g <br />Street Number Direction <br />cv (.--,2 <br />Street Name C - - 4-- SfoCkfon <br />City <br />9 5 ZO 7 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from SiteAddress) <br />SS CS PI avulOreS 4- C‘r Street Number Street Name <br />CITY STATE <br />ZIPS '1,0 7 <br />PHONE #1 Err. <br />(109 ) 2)12 --Ws 3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />(201 ) LI 30 — 5094 <br />EMAIL e)0,,,,An oeriail. Corn <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ct._ CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP EMAIL <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br />will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: JA )9, Zo2.3 <br /> <br />PROPERTY / BUSINESS OWNER 0 OP ATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my <br />representative. <br /> PA • <br />TYPE OF SERVICE REQUESTED: RECei—w <br />I. I lye vt,1 ki2-,A,44,-( sql\v-e RECEIVED ...is <br />COMMENTS: <br />JUL 1 9 2023 <br />qovar\(\100 k4)//c)c) SAN JOAQUIN ,..,5,NviRo ECOUNTY NTAL. --Th DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: 7 <br />ASSIGNED TO: IA ....[,,,,,-- EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: _<--; P/E: /6,6 / <br />Fee Amount: Amount Paid Li <br />I- <br />Payment Date ---+ (( 41( '23 <br />Payment Type (\ ra 61 Invoice # na4f: / Le "6-429-46e(p Received By: akr-A2( <br />SR FORM (Golden Rod) EHD 48-02-025 <br />03/22/23